Plastic Bronchitis and Protein Losing Enteropathy in Children With Single Ventricle Physiology

Protein losing enteropathy (PLE) has emerged as an increasingly common complication of
single ventricle palliation in children born with cyanotic congenital heart disease. This
entity becomes manifest months or years after the modified Fontan operation and is thought
to affect 5-15% of all patients with Fontan physiology. Patients with PLE often suffer from
symptoms related to severe hypoproteinemia and intestinal malabsorption, including edema,
ascites, pleural and pericardial effusions, chronic diarrhea and poor growth. Mortality is
strikingly high, with only 50% of patients surviving for more than 5 years following
diagnosis. The pathophysiology is poorly understood and several theories are presented as
possible mechanisms which includes: 1) chronic low cardiac output and intestinal injury
leading to loss of intestinal integrity, 2) chronic intestinal inflammation leading to loss
of intestinal integrity, 3) chronic elevated portal venous pressure with intestinal injury
leading to loss of intestinal integrity. Treatment is sporadically successful and has
included 1) creating a fenestration between the Fontan pathway and pulmonary venous atrium
which decreases Fontan pressure and increases cardiac output, 2) chronic use of
unfractionated or low molecular weight heparin to reconstitute the intestinal basement
membrane, 3) Use of oral steroids to reduce intestinal inflammation, 4) Use of pulmonary
vasodilators to reduce Fontan pressure and increase cardiac output 5) implantation of
pacemakers to treat sinus node dysfunction and improve cardiac output, 6) heart
transplantation. Short of cardiac transplantation, no treatment of PLE, including efforts
to change systemic and/or gastrointestinal hemodynamics, is routinely successful. Thus, it
appears that the etiology of PLE is more complex than simply "high venous pressure in the
gut" as has been previously believed.

A second entity seen in patients after modified Fontan procedure is "plastic bronchitis"
(PB). This is a highly morbid clinical picture of persistent production of high
mucoprotein-containing airway secretions that causes severe airway obstruction leading to
increased work of breathing, V/Q mismatch and progressive respiratory failure leading to
death. The etiology of plastic bronchitis is not understood at all and beyond supportive,
palliative measures such as lung lavage, there is no current treatment for plastic
bronchitis.

VIP and Substance P are both small peptides with significant autocrine and paracrine
signaling ability. The role of VIP in controlling gut protein and solute secretion has been
understood for approximately 20 years. The clinical entity where this has been best
described are in rare "VIP-omas" and some other chromophore secreting gut tumors where
massive amounts of VIP are secreted by the tumor and overwhelm the body's normal ability to
clear VIP through cleavage by neutral endopeptidases in the pulmonary endothelium.

Until very recently, Substance P was known primarily for its role in peptidogenic signaling
in sensory pathways. As described below, an important and previously not understood role for
Substance P in the control of human airway mucus secretion has recently been described.

Scientific Basis for Proposed Research:

The basis for this proposal arises from three, independent streams of research.

1. First, extensive investigations in patients with increased portal venous pressures,
usually from cirrhosis, has shown that increased portal venous pressures lead to
significant increases in the excretion of a wide variety of small peptide signaling
molecules. Included in these molecules are VIP, 5-HT and Substance P.As patients with
Fontan physiology always have increased portal and gut venous pressures as a direct
consequence of their anatomic palliation, it stands to reason that they should likewise
have increased GI production of these signaling peptides.

2. Second, clearance of gut-derived signaling peptides such as VIP, Substance P,
angiotensin, brandykinin and others occurs primarily in the lungs via peptide cleavage
catalyzed by the neutral endopeptidases, a class of enzymes heavily resident in the
pulmonary circulation. The role of the neutral endopeptidases is to cleave and thus
inactivate small peptides and 'protect" the systemic circulation from the plethora of
vasoactive peptides that come from the systemic circulation. With respect to the
potential role of VIP and/or Substance P in the etiology of PLE or PB, it is important
to note that in patients with Fontan physiology current practice is to fenestrate the
Fontan shunt to allow some portion of the systemic venous blood flow to bypass the
lungs. Thus, any vasoactive / signaling peptides returning in the lower body systemic
venous circulation will bypass the pulmonary clearance mechanisms in proportion to the
degree of fenestration shunt at the moment. This pulmonary clearance bypass physiology
is relative unique in medicine to older patients with Fontan-palliated congenital heart
disease and thus may be, in part, the basis that PLE and PB are seen almost uniquely in
Fontan patient.

Further implicating derangements in active peptide clearance physiology in the etiology
of PLE and PB is the fact that the classic member of the neutral endopeptidase class is
(the misnamed) Angiotensin Converting Enzyme (ACE) , which actually cleaves a number of
these small peptide signaling molecules including VIP and Substance P. Virtually all
patients with Fontan physiology are on large doses of ACE-inhibitors to lower systemic
afterload. Captopril-induced inhibition of VIP and Substance P inactivation would
significantly increase already elevated systemic levels of these signaling peptides and
further potentiate the etiology of PLE and PB in Fontan-palliated patients. Variations
of neutral endopeptidase inhibitor ("ACE inhibitor" ) drug dosage and/or genotype
variation of ACE which causes dramatically altered activity can in part explain the
variable incidence of PLE and PB in Fontan physiology patients. In this study, the use
and dose of ACE inhibitor that each patient is on will be recorded to see if there is a
correlation between ACE inhibitor dose and measured VIP and Substance P levels. There
are wide variation of ACE gene genomics that have been described for decades.
Intriguingly, approximately 10-15% of all persons have a newly described genomic
variation of the ACE gene which leads to profoundly reduced circulating levels of ACE
and increased susceptibility to ACE inhibition and 10-15% of patients with Fontans
develop PB or PLE.

3. Lastly, very recent work has completely changed our understanding of the control of
normal, basal mucus and solute secretion in the human airways and gut. Here-to-fore it
was believed that cholinergic mechanisms controlled airway mucus secretion. This recent
and still emerging work shows that in fact it is VIP and Substance P which act
individually and synergistically in the control of both normal basal human airway
mucus production and in regulating gut secretion. This very new work gives a unifying
hypothesis to the seemingly disparate entities of PLE and PB: since Substance P and VIP
control normal basal human airway secretion and stimulated human gut protein secretion,
increases in pulmonary venous and/or gut arterial levels of these peptides can be the
basis for PLE and PB. The GI, cardiac and pulmonary physiology and pharmacologic
treatment of patients with fenestrated Fontans is a perfect setting for this
interaction to occur.

Taken in totality, these three streams of independent research give a strong basis for the
hypothesis that the palliative physiology and pharmacologic treatment of Fontan patients
leads to increased levels of VIP, Substance P or both, and they may be causal in the
pathophysiology of PB and PLE.

Rationale for Current Study Design and Subject Recruitment:

Consistent with our Aims and Hypotheses, four patient groups will be studied: i)Fontan
Physiology Patients with PLE and PB Patients ii) Fontan Physiology Patients without PLE and
PB iii) Patients with Glenn Physiology Congenital Heart Disease and iv) Patients with 2
ventricle physiology and an atrial septal defect who will serve as a Control group.
Measurement of mixed venous and arterial levels of substance P and VIP in these 4 groups of
subjects will allow us to determine the effects of elevated portal venous pressure on the
production and clearance of substance P and VIP and well as the effects of altered
hepatic-pulmonary blood flow on the clearance of substance P and VIP. This should allow us
to determine if 1) systemic arterial levels of substance P and VIP levels are elevated in
Fontan patients when compared to controls, and if elevated, 2) whether this is due to
increased hepatic production, reduced pulmonary clearance or both. The rationale for the
inclusion of each patient group is summarized below.

Subjects with Fontan physiology (Group I and II) have a unique physiology where both the
superior vena cava (SVC) and inferior vena cava (IVC) are connected directly to the
pulmonary arteries thereby bypassing the heart. This palliation scheme allows for
separation of the pulmonary and systemic circulations in patients with univentricular hearts
and essentially eliminates cyanosis. These patients have non-pulsitile pulmonary artery
flow with elevated central venous and portal venous pressures. Therefore, it is suspected
that these patients will have increased production of substance P and VIP. In addition, a
fenestration (or hole), is created between the Fontan conduit and the atrium at the time of
Fontan surgery in order to lower central venous pressure and increase cardiac output by
creating a right to left intracardiac shunt. It is suspected that these patients will have
elevated systemic venous and arterial levels of vasoactive peptides as a result of 1)
increased hepatic/gut production, 2) decreased pulmonary vascular clearance, and/or 3)
intracardiac right to left shunting. Studying these subjects will allow us to determine how
systemic venous and systemic arterial levels of Substance P and VIP are altered by the
Fontan circulation. By comparing systemic arterial and venous levels of vasoactive peptides
among control, Glenn physiology and Fontan physiology groups we hope to measure differences
in vasoactive peptide levels that could be responsible for the development of PLE and PB in
Fontan physiology patients.

Subjects with Glenn physiology (Group III) have a unique physiology where hepatic venous and
lower body venous blood returns to the heart and enters the systemic ventricle and is
recirculated to the body after combining with the pulmonary venous blood. There is no
direct connection thru the heart for hepatic venous blood to enter the pulmonary arteries.
Therefore, it is suspected that these patients will likely have elevated systemic arterial
circulating levels of Substance P and VIP due to intracardiac right to left shunting and
reduced pulmonary clearance. However, since these patients typically have normal portal
venous pressures, they are not thought to have increased production of these vasoactive
peptides. In addition, these patients historically are not at risk for developing PLE and
PB. Studying these subjects will allow us to determine how systemic venous and systemic
arterial levels of Substance P and VIP are altered by the Glenn circulation. By comparing
systemic arterial and venous levels of vasoactive peptides among control, Glenn physiology
and Fontan physiology groups we hope to measure differences in vasoactive peptide levels
that could be responsible for the development of PLE and PB in Fontan physiology patients.

Control group subjects (Group IV) will have normal hepatic-pulmonary blood flow and normal
portal venous pressures. An atrial septal defect allows for left to right shunting of blood
thru the heart but does not typically result in elevated pulmonary artery or right
ventricular pressures. These subjects will have normal flow of hepatic venous blood into
the pulmonary capillary bed. Therefore they should have normal hepatic production and
pulmonary clearance of substance P and VIP.

Inclusion Criteria:

- Fontan physiology patients with PB or PLE

- Fontan physiology patients without PB or PLE

- Glenn physiology patients

- 2 ventricle patients with Atrial Septal Defect

- Patient has scheduled cardiac catheterization (of right and left heart)

- Age is greater than 6 months

- Weight is greater than 10kg

Exclusion Criteria:

- Known Inflammatory Bowel Disease

- Hepatitis

- Congenital/ acquired liver disease

- Nephropathy

- Acute/ chronic renal dysfunction

- Active pulmonary hemorrhage

- Malignancy